Direct Oral Challenge is Non-inferior to Skin Testing in Low-risk Penicillin Allergy Patients
Clinical question: Is there an alternative to penicillin skin testing for low-risk penicillin allergies?
Dr. Miller
Background: While approximately 10% of the population report penicillin allergies, studies indicate that more than 95% of these individuals will have negative allergy testing and can tolerate penicillin. The current gold standard for relabeling a penicillin allergy involves skin testing followed by direct oral challenge. However, specialized allergy skin testing is not universally accessible, and can be labor-intensive and costly. Moreover, skin testing alone doesn’t conclusively demonstrate penici...
Source: The Hospitalist - October 2, 2023 Category: Hospital Management Authors: Ronda Whitaker Tags: Clinical Guidelines In the Literature Source Type: research
Deprescribing Medications Among Older Adults from the End of Hospitalization Through Post-acute Care
Clinical question: Can inpatient deprescribing interventions upon post-acute care facility discharge reduce the total medication burden?
Dr. Kaur
Background: Polypharmacy remains a common concern in elderly patients due to associated adverse health outcomes. While deprescribing can be an important therapeutic intervention, it is usually practiced in primary care settings. There is underutilization of deprescribing in inpatient settings due to limited data and unclear information on the safety and effectiveness of deprescribing.
Study design: Randomized controlled trial, May 2016 to October 2020
Setting: Vanderbilt Un...
Source: The Hospitalist - October 2, 2023 Category: Hospital Management Authors: Ronda Whitaker Tags: Geriatrics In the Literature Source Type: research
Weighing Benefits and Risks of Indefinite Anticoagulation in First Unprovoked VTE
Clinical question: Is indefinite anticoagulation beneficial for patients with a first unprovoked venous thromboembolism (VTE) after initial treatment?
Dr. Sheikh
Background: VTE is a chronic, recurrent condition with significant health care costs. While guidelines recommend indefinite anticoagulation for a first unprovoked VTE, the balance between benefits and harms remains debated.
Study design: Markov modeling study
Setting: Canadian health care public payer perspective
Synopsis: In a hypothetical cohort of 1,000 patients aged 55 years with a first unprovoked VTE, indefinite anticoagulation using direct oral anticoagul...
Source: The Hospitalist - October 2, 2023 Category: Hospital Management Authors: Ronda Whitaker Tags: Circulatory In the Literature Source Type: research
Pitavastatin and Cardiovascular Disease Prevention in HIV Patients
In this study of 7,769 virally suppressed HIV-infected individuals (median age 50), the efficacy of pitavastatin calcium (4 mg daily) was compared to a placebo in preventing major cardiovascular events. Over a median follow-up of 5.1 years, the pitavastatin group exhibited a reduced event rate of 4.81 per 1,000 person-years, compared to the placebo group’s 7.32. This translated to a hazard ratio of 0.65. However, the pitavastatin group reported increased muscle-related symptoms and a higher incidence of diabetes mellitus. The study’s limitations include its relatively short duration, focus on a healthier HIV cohort, an...
Source: The Hospitalist - October 2, 2023 Category: Hospital Management Authors: Ronda Whitaker Tags: In the Literature Infectious Diseases Source Type: research
No Difference Between Liberal Versus Strict Perioperative BP Management in Non-cardiac Surgery
Clinical question: In patients on antihypertensive medications (AHMs) such as angiotensin-converting-enzyme inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) undergoing inpatient non-cardiac surgery, what blood pressure (BP) management strategy reduces the risk of major vascular complications?
Dr. Subramany
Background: Perioperatively, both hypotension and hypertension can lead to vascular complications after non-cardiac surgery. There is a lack of large robust trials that inform how AHMs should be managed; there is conflicting data regarding what the minimal intraoperative mean arterial pressure should be to r...
Source: The Hospitalist - October 2, 2023 Category: Hospital Management Authors: Ronda Whitaker Tags: In the Literature Surgery Source Type: research
DAPT Non-inferior to Alteplase for Minor AIS
Clinical question: Is dual antiplatelet therapy (DAPT) non-inferior to intravenous (IV) thrombolysis in patients with minor non-disabling acute ischemic strokes (AIS)?
Dr. Subramany
Background: Minor strokes comprise about half of all AIS but the evidence for IV thrombolytics in this cohort has been inconclusive. While prior studies have confirmed the superiority and safety of short-term DAPT in acute minor strokes compared to aspirin alone; no studies have previously compared DAPT versus IV thrombolytics.
Study design: Multi-center, randomized, open-label, blinded endpoint assessment, non-inferiority trial
Setting: 38 h...
Source: The Hospitalist - October 2, 2023 Category: Hospital Management Authors: Ronda Whitaker Tags: In the Literature Neurology Source Type: research
Intensive BP Control with PO or IV Harmful in Hospitalized Older Adults
Clinical question: How do clinical outcomes compare between patients with asymptomatic hypertension treated intensively versus not while hospitalized?
Dr. Richardson
Background: While the long-term cardiac effects of untreated hypertension are clear, the short-term in-hospital consequences of hypertension remain uncertain. Previous studies have indicated that lowering blood pressure in hospital can lead to hypotension and acute kidney injury (AKI).
Study design: Retrospective observational cohort study
Setting: Veterans Affairs (VA) hospital
Synopsis: In a study of 66,000 white, male, VA patients aged over 65, 14,000 rec...
Source: The Hospitalist - October 2, 2023 Category: Hospital Management Authors: Ronda Whitaker Tags: Geriatrics In the Literature Source Type: research
Delayed Antibiotics in Suspected Sepsis Increase Shock Risk and Mortality
This study evaluated the risk of progression to shock and subsequent mortality in patients not yet diagnosed with sepsis.
Study design: Retrospective cohort study
Setting: University of Kansas Hospital Emergency Department
Synopsis: From March 2007 to March 2020, more than 74,000 patients aged 18 or older with suspected but unconfirmed sepsis were evaluated; 7.4% (5,510) of patients progressed to septic shock. On evaluation, patients who appeared sicker on presentation (with higher quick sequential organ failure assessment, or qSOFA, and systemic inflammatory response syndrome, or SIRS, scores) progressed to shock more oft...
Source: The Hospitalist - October 2, 2023 Category: Hospital Management Authors: Ronda Whitaker Tags: In the Literature Infectious Diseases Source Type: research
Onco-Hospitalists Bring Value to Patient Care
Most working hospitalists will see cancer patients regularly on their hospital rounds since it’s the main underlying condition for many hospital admissions—whether for the disease itself, side effects from cancer treatments, or possibly coincidental medical issues.
But a smaller number of hospitalists are focusing their practices on oncology patients, working with oncologists who—like many outpatient-based physicians before them throughout the history of hospital medicine—have found it ever harder to make in-person visits to their patients in the hospital.
At Memorial Sloan Kettering Cancer Center (MSKCC) in New Yo...
Source: The Hospitalist - October 2, 2023 Category: Hospital Management Authors: Ronda Whitaker Tags: Career Oncology Patient Care Source Type: research
Best Approach to a Cavitary Lung Lesion – Update
This is an update of our 2015 article on cavitary lung lesion.1
Case
A 60-year-old man with alcohol use disorder presented to the hospital with fatigue, chest pain, and productive cough for two weeks. Additionally, he endorsed a 20-lb weight loss over the previous month which he attributed to a poor appetite. He lived in the southwestern U.S. and had no recent travel. His initial chest X-ray demonstrated a 3.4-cm left upper lobe cavitary lesion (Figure 1).
Overview
Hospitalists frequently encounter patients with cavitary lung lesions on chest imaging and are often faced with initiating their early workup and management. Ha...
Source: The Hospitalist - October 2, 2023 Category: Hospital Management Authors: Ronda Whitaker Tags: Clinical Clinical Guidelines Pulmonology Source Type: research
Waves
There we go again.
I’m sorry honey. I don’t know why it starts beeping suddenly. I hate to keep bothering you all night.
Well, to be honest, my breathing has been a little shallow tonight. Yes, the breathing treatment did help. But only for a bit.
I’m not sure. They keep telling me it’s the fluid in my lungs. I do try to do as they tell me. Not drinking much water during the day. But this fluid just keeps coming back.
They say it’s related to my heart. Cardio-mayo-something. I don’t know. I don’t get much of what they say.
It’s funny in a way, actually. I spent half my life teaching kids how to brave th...
Source: The Hospitalist - September 8, 2023 Category: Hospital Management Authors: Lisa Casinger Tags: Poetry Source Type: research
Movers and Shakers September 2023
Dr. Mgbokikwe
Nkemdilim Mgbojikwe, MD, has joined Fox Chase Cancer Center, Philadelphia, as associate chief medical officer; she will also serve as an associate professor and hospitalist in the department of medicine.
Prior to joining Fox Chase Cancer Center, Dr. Mgbojikwe was clinical director of the division of hospital medicine, medical director for four med-surg inpatient units, and medical co-director of the medicine progressive care unit at Johns Hopkins Hospital, director for acute virtual care strategy at Johns Hopkins Health System, and assistant professor of medicine at Johns Hopkins University School of Medicin...
Source: The Hospitalist - September 1, 2023 Category: Hospital Management Authors: Lisa Casinger Tags: Career People in HM Source Type: research
Early Restrictive Fluid Strategy Didn ’t Lower Mortality for Sepsis-induced Hypotension
Dr. Klein
Clinical question: Does a restrictive fluid strategy within the first 24 hours improve all-cause mortality among patients with sepsis-induced hypotension?
Background: There are limited data to guide the specific use of intravenous (IV) fluids or vasopressors in the early resuscitation of patients with sepsis-induced hypotension. Previous observational data suggested that a restrictive fluid strategy that prioritized vasopressors was potentially superior to a liberal fluid strategy. However, a recent, randomized, clinical trial in patients already admitted to the intensive care unit (ICU) showed no difference in ...
Source: The Hospitalist - September 1, 2023 Category: Hospital Management Authors: Ronda Whitaker Tags: Clinical Guidelines In the Literature Source Type: research
Sustained Reduction in Lab Ordering After Implementing Mindful Ordering Initiatives
This study included 86 to 92 residents and 17 to 20 faculty per year, rotating through a general-medicine inpatient teaching service between 2016 and 2019. Interventions were implemented in five phases, which included resident education, promotion of faculty-resident communication, optimization of EMR by expanding lab ordering frequency options, adjusting the medicine admission order set, and reducing the frequency of lab collection default settings.
Survey data showed an increase in the percentage of residents who perceived themselves as ordering labs mindfully from 40% at week 31 to 91% at week 127 (P <.05). Total lab...
Source: The Hospitalist - September 1, 2023 Category: Hospital Management Authors: Ronda Whitaker Tags: Clinical Guidelines In the Literature Source Type: research
Prioritizing Discharging Patients While Rounding Didn ’t Result in Earlier Discharge Times or Reduced LOS
Dr. Klein
Clinical question: Does a physician rounding style prioritizing discharging patients lead to earlier discharges or reduced length of stay (LOS)?
Background: Delayed discharges can adversely affect patient flow throughout the hospital, leading to delays of care, increased LOS, higher cost, and potentially increased mortality. Prioritizing discharges by a specific time has shown mixed results in prior studies. There have been no previous randomized studies to assess the efficacy of a rounding style prioritizing discharges.
Study design: Prospective, multicenter, randomized, controlled trial
Setting: Three large a...
Source: The Hospitalist - September 1, 2023 Category: Hospital Management Authors: Ronda Whitaker Tags: Clinical Guidelines In the Literature Source Type: research
